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ENVIRONMENTAL HEALTH DIVISION <br /> APPLICATION FOR UNDERGRLUNO TANK RETROFIT, TANK LINING, 02 PIPING REPAIR PERMIT <br /> THIS PERMIT EXPIRES 90 DAYS FRQM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW- <br /> 1 <br /> TANK REPAIR/RETROFIT -_TANK LINING PIPING REPAIR <br /> PADORESS <br /> PROJECT CONTACT $ TELEPHONE <br /> F ` PHONE <br /> A 9 370 <br /> CI <br /> LI <br /> T <br /> Y PHONE QD i Q-9b <br /> R y2 <br /> C CONTRACTOR NAME PHONE 3 <br /> O <br /> TCONTRACTOR ADORES <br /> D 007 CLASSP / H <br /> �fiZ <br /> _ <br /> INSURER WORK.COMP.S <br /> / <br /> A <br /> C OTHER INFORMATION <br /> T <br /> Cl <br /> R PHONE 9 <br /> PHONE 0 <br /> 11111111lI1111111(11111111111i <br /> 39- <br /> TANK 10 ,i - TANK SIZE CHEMICALS STORED CURRENTLY/PREVICUSLY DATE ST INSTALLED <br /> � n <br /> T 39- <br /> , <br /> A 39- J7 <br /> K 39 <br /> 39- <br /> 39- <br /> Ilil <br /> P <br /> APPROVED _ APPROVED WITH GOND ITION(S) _ DISAPPROVED I V i 00 <br /> A P'^ <br /> PUN REVIEWERS NAME �/ (SE ACRMENT WITH CONDITIONS) <br /> M /YI/' DATE <br /> IIIlIIIl111t1111111111J1 11l711111I11lIIII1111! 1111111 lillllllllllllllil 1 I Illliltlillllllilli !il Illlltl 111.1111111 <br /> APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGE'NT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br /> THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANT PERSON IN SUCH A MANNER AS TO BECOME <br /> SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: <br /> 'I CERTIFY THAT IN THE PE. NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WCRKER'S <br /> CC.NPENSATIQV LAWS OF GLI 0 IA.^ <br /> APPLICANT'S SIGNATURE: - i'� �`--T ' TI DATE <br /> LING INFORMATION:. <br /> icate the responsible parry to be billed for additional PHS-E4D staff time expended beyond permit payment coverage per tank. If the <br /> ty designated beton is different than the permit applicant, e_g_ property owner, the party must acknowledge this responsibility for <br /> biLPing by signatu date belo <br /> ting Address /q <br /> Phone Nunber (� <br />